Purpose Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, ...natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single‐port laparoscopic colorectal surgery using a Uni‐X™ Single‐Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi‐channel cannula and specially designed curved laparoscopic instrumentation.
Method The abdomen was approached through a 3.5 cm incision via the umbilicus and a single‐port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device™ (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis.
Results The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae.
Conclusion Single‐port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient’s umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.
To present our initial experience with single-port percutaneous transvesical simple prostatectomy using the novel SP robotic surgical system.
Ten patients underwent single-port transvesical simple ...prostatectomy between February and November 2019. Percutaneous access to the bladder dome was made and all SP instruments were inserted through the SP multichannel cannula directly into the bladder. Prostate adenoma enucleation, hemostasis and trigonization were done according to the principles of open simple prostatectomy technique. Demographics and perioperative outcomes were prospectively collected and analyzed.
All procedures were performed successfully without the need for conversion to open surgery. Median preoperative estimated prostate size was 159 (Interquartile range (IQR) 108-223) grams.
No intraoperative complications occurred. Median operative time and estimated blood loss were 190 (IQR 146-203) minutes and 100 (IQR 68-175) ml, respectively. Mean postoperative specimen weight was 84.3 ± 34 grams. Median length of hospital stay was 19 (IQR 17-28) hours. All patients were satisfied with their urinary flow after catheter removal without any episode of acute urinary retention 1-6 months, postoperatively.
Single-port transvesical simple prostatectomy can be offered as an alternative treatment option for surgical management of lower urinary tract symptoms associated with large prostate adenoma. Sparing the peritoneal cavity, minimum dissection of the bladder, excellent visualization of the prostate fossa can be some of the potential advantages of this minimally invasive approach. Comparative studies with standard techniques are advisable to evaluate the surgical outcome and postoperative morbidity of each treatment modality.
Objectives
To evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy (PN).
Materials and methods
Retrospective study of 1042 patients who ...underwent PN for cT1N0M0 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged as pT1. Demographic, perioperative and pathological variables were reviewed. We compared the clinico-pathological characteristics, perioperative morbidity and oncological outcomes between pT3a and pT1 groups. Multivariate regression evaluates variables associated with T3a upstaging. Recurrence-free survival (RFS) and overall survival analyses were performed. Survival curves were compared using log-rank test.
Results
The pT3a tumors were high complexity tumors (median RENAL score 8 vs. 7,
p
< 0.01), higher hilar (h) location (27.5 vs. 14.8%,
p
< 0.01), higher grade (57.5 vs. 38.2%,
p
< 0.01), and higher positive surgical margins (18.6 vs. 5.8%,
p
< 0.01. Patients with pT3a had a higher estimated blood loss, transfusion rate, ischemia time and overall complications, though there were no differences in median e-GFR decline and major (Grade III-V) complications. Five-year RFS was 78.5% for pT3a group vs. 94.6% for pT1 group (log-rank
p
< 0.01). Male gender (OR 2.2,
p
< 0.01), and R.E.N.A.L. score (OR 2.3,
p
= 0.01) were preoperative predictors of upstaging. We acknowledge limitations in our study, most are inherent problems of retrospective studies.
Conclusion
Perioperative morbidity, after partial nephrectomy, is acceptable in cT1/pT3 tumors in comparison to cT1/pT1; however, upstaged patients had a worse oncological outcome. cT1/pT3a tumors are associated with adverse clinico-pathological features. Preoperative risk predictors of upstaging were higher R.E.N.A.L. score and male gender.
Single Port (SP) robotic partial nephrectomy (RPN) can be performed via retroperitoneal and transperitoneal approach. We aim to compare outcomes of two commonly described incisions for ...retroperitoneal SP RPN: lateral flank approach (LFA) and low anterior access (LAA). We performed a retrospective study of patients who underwent SP retroperitoneal RPN from 2018 to 2023 as part of a large multi-institute collaboration (SPARC). Baseline demographic, clinical, tumor-specific characteristics, and perioperative outcomes were compared using
χ2
,
t
test, Fisher exact test, and Mann–Whitney
U
test. Multivariable analyses were conducted using robust and logistic regressions. A total of 70 patients underwent SP retroperitoneal RPN, with 44 undergoing LAA. Overall, there were no significant differences in baseline characteristics between the two groups. The LAA group exhibited significantly lower median RENAL scores (8 vs. 5,
p
< 0.001) and more varied tumor locations (
p
= 0.002). In the bivariate analysis, there were no statistically significant differences in ischemia time, estimated blood loss, or complication rates between the groups. However, the LAA group had longer operative times (101 vs. 134 min,
p
< 0.001), but was more likely to undergo a same-day discharge (
p
< 0.001). When controlling for other variables, LAA was associated with shorter ischemia time (
p
= 0.005), but there was no significant difference in operative time (
p
= 0.348) and length of stay (
p
= 0.122). Both LFA and LAA are acceptable approaches for SP retroperitoneal RPN with comparable perioperative outcomes. This early data suggests the LAA is more versatile for varying tumor locations; however, larger cohort studies are needed to ascertain whether there is an overall difference in patient recovery.
Partial nephrectomy is performed with the aim to preserve renal function. But the occurrence of postoperative acute kidney injury (AKI) can interfere with this goal. Our primary aim was to evaluate ...associations between pre-specified modifiable factors and estimated glomerular filtration rate after partial nephrectomy. Our secondary aims were to evaluate associations between pre-specified modifiable factors and both serum creatinine concentration and type of nephrectomy.
The records of 1955 patients who underwent partial nephrectomy were collected. Postoperative estimated glomerular filtration rate (eGFR) was used as the primary outcome measure. Twenty modifiable risk factors were studied. A repeated-measures linear model with autoregressive within-subject correlation structure was used. The interaction between all the factors and type of nephrectomy was also studied.
A total of 1187 (61%) patients had no kidney injury, 647 (33%) had stage I, 80 (4%) had stage II, and 41 (2%) had stage III injury. The mean eGFR increased an estimated 0.83 (99.76% CI 0.79–0.88) ml min−1 1.73 m−2 for a unit increase in baseline eGFR. Mean eGFR was 2.65 (99.76% CI: 0.13, 5.18) ml min−1 1.73 m−2 lower in patients with hypertension. Mean eGFR decreased 0.42 (99.76% CI: 0.22, 0.62) ml min−1 1.73 m−2 for a 10-minute longer in duration of procedure and decreased 2.09 (99.76% CI: 1.39, 2.80) ml min−1 1.73 m−2 for a 10-minute longer in ischemia time. It was 3.53 (99.76% CI: 0.83, 6.23) ml min−1 1.73 m−2 lower for patients who received warm ischemia as compared to cold ischemia.
Potentially modifiable factors associated with AKI in the postoperative period were identified as baseline renal function, preoperative hypertension, longer duration of surgical time and ischaemia time, and warm ischaemia.
Treatment options for a suspicious renal mass in a renal allograft include radical nephrectomy or nephron‐sparing surgery (NSS). To our knowledge robotic‐assisted laparoscopic partial nephrectomy ...(RPN) as treatment for a renal mass in a transplant kidney has not been previously reported. We report the case of RPN for a 7‐cm renal mass in a transplanted kidney. A 35‐year‐old female with reflux nephropathy received a living‐related donor kidney transplant in 1986. At 24 years after transplantation she had a 7‐cm Bosniak III cystic mass of the allograft detected on computerized tomography (CT) scan. Preoperative creatinine was 2.2 mg/dL with an estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m2. RPN was performed with bulldog clamping of the renal vessels, the graft was left in situ and immunosuppression was maintained postoperatively. Tumor diameter was 7.3 cm with a nephrometry score of 10a. Warm ischemia time (WIT) was 26.5 min. Estimated blood loss was 100 mL. There was no change between pre‐ and postoperative eGFR. There were no operative complications. Histology was papillary renal cell carcinoma type 1, nuclear grade 2. Margins were negative. RPN is a technically feasible treatment option for a suspicious renal mass in renal allografts.
Robotic‐assisted laparoscopic partial nephrectomy in a renal allograft is feasible.
INTRODUCTIONTo present the first case of a concomitant robotic radical prostatectomy and a left robotic partial nephrectomy performed by a single-port approach using the SP® da Vinci surgical system ...(Intuitive Surgical, Sunnyvale CA, EE.UU.). PATIENT AND METHODSA 66-year-old male diagnosed with localized prostate cancer and a left kidney renal mass incidentally found on computed tomography (CT) scan during prostate cancer evaluation. Procedures were performed using a single supra-umbilical 3cm incision, plus one additional laparoscopic port, utilizing a standard Gelpoint® (Applied Medical, Rancho Santa Margarita, CA, EE.UU.) and replicating the technique previously described for single-port transperitoneal radical prostatectomy and partial nephrectomy with the use of the SP® robotic platform. RESULTSTotal operative time was 256minutes (min) with a console time of 108min for radical prostatectomy, and 101min for the partial nephrectomy respectively, including a warm ischemia time of 26min. Estimated blood loss was 250cc. Blood transfusion was not needed. Final pathology for prostate was adenocarcinoma Gleason 7 (4+3) and for the kidney lesion was renal cell carcinoma. After two months of follow-up, PSA was undetectable and no complications or recurrence were detected. CONCLUSIONSThe single-port approach has advantages as easier surgical planning and transition for combined and multi-quadrants surgeries: faster recovery, minimal postoperative pain and need for opioids, and excellent cosmetic outcome. We suggest that combined procedures should be performed only in high volume institutions by surgeons with vast experience in robotic surgery in selected patients.
Prostatic utricles have traditionally been excised via the open approach or laparoscopically. Recently, the robot-assisted laparoscopic approach has been described in a 19-year-old male. the case of ...a 3-year-old male with a disorder of sex development (mosaic 45X/46 XY), with multiple associated anomalies, who presented with recurrent UTI is presented. Renal/bladder ultrasound revealed normal bilateral kidneys, and a 4.3 × 2.8 × 3.3 cm cystic mass in the midline posterior to the bladder. Voiding cystourethrogram demonstrated a large cystic mass behind the bladder, concerning for large prostatic utricle.
The patient was brought to the operating room and placed in lithotomy. The urethra was examined cystoscopically. The os of the utricle was identified, an open-ended catheter was advanced, the cystoscope was removed, and a Foley was placed.
The camera port was introduced supraumbilically, and robotic ports were introduced inferolaterally. Irrigation of the catheter and distension of the utricle allowed manipulation of the utricle to facilitate identification of a plane of dissection. The neck of the utricle was identified and incised. The catheter was removed, transection was completed, and the stump was oversewn.
Combined cystoscopic and robotic approach to prostatic utricle excision is feasible, safe, and effective in this patient population.
The aim of the present study was to compare the outcomes of Off-Clamp to On -Clamp approach during robot-assisted partial nephrectomy (RAPN).
Retrospective study of 940 patients who underwent a RAPN ...between 2007 and 2015 for cT1a tumors using On-Clamp or Off-Clamp approaches. Patient with solitary kidney or multifocal were excluded. Overall, 103 patients underwent Off-Clamp approach and 37 patients On-Clamp approach. We matched the patients in terms of tumor size, Charlson comorbidity index and R.E.N.A.L. score. At all, 309 patients from the On-Clamp were matched to the Off-Clamp group. We compared the clinic-pathological characteristics, perioperative morbidity and late functional outcomes between the 2 propensity score matched groups. Limitation included retrospective analysis.
After matching, there were no difference in clinic-pathological characteristics in terms of gender, age, race, body mass index, Charlson comorbidity index, American Society of Anesthesiologists score, baseline estimated glomerular filtration rate (e-GFR), tumor size, R.E.N.A.L. score complexity, hilar (H) location between the 2 groups. Regarding perioperative outcomes; while operative time (P=0,4), estimated blood loss (P=0,28), Clavien grade III-IV complications (P=0,8) surgical reoperation (P=1), 30-day readmission (P=1), positive surgical margin (5,5% vs. 5,8%, P=0,9) were comparable between the 2 groups, there were significant difference in excisional volume loss (median, 7,08 vs. 3,51cm
, P<0,01), e-GFR decline (median, -9,7 vs. -2,2ml/min/1,73 m
, P<0,01), percent of e-GFR preservation (median, 87% vs. 97%, P<0,01), and CKD upstaging (36,5% vs. 23,3%, P=0,01), Off-Clamp approach (P=0,01), and age (P=0,02) were predictors of renal function preservation, whereas excisional volume loss (OR=1,035, CI 95% (1,015-1,06), P<0,01) predicted upstaging.
RAPN for selected renal mass using Off-Clamp approach offered renal functional advantage over On-Clamp, without adding morbidities. While no ischemia technique was associated with less excisional volume loss, Off-Clamp approach, and age were independent predictors of renal function preservation. Clinical significance of these findings in various clinical settings will require further investigation.
The novel da Vinci Single-Port (SP) robotic platform received the US FDA approval in 2018. The device, specifically conceived for single-site approach, is pushing through the limits of minimally ...invasive surgery. We sought to provide a comprehensive overview of the current status of the clinical experiences accomplished by the da Vinci SP in urology, and to discuss future perspectives.
A non-systematic literature review was performed focusing on single port articles in urological surgery using Medline/PubMed and Embase search electronic engines. The authors analyzed findings and a brief report of the clinical experience for surgical procedures completed by the SP platform was described.
The current data available from single-port robotic established the safety and feasibility of urologic procedures using this novel platform. However, the results come from single-center case series, small cohorts and retrospective studies that need to be cautiously interpreted. Additional evidence is required to determine the asset of the SP platform in the urological community.
The SP robotic system opens new frontiers on the surgical scenery facilitating the completion of urological surgeries through a single incision. Further comparative studies will be required to assess perioperative and long-term oncological and functional outcomes among SP, multi-arm robotic and open approaches.
La novedosa plataforma robótica da Vinci Single-Port (single port SP = puerto único PU) recibió la aprobación de la FDA en 2018. El equipo, concebido específicamente para el acceso por un solo puerto, está superando los límites de la cirugía mínimamente invasiva. Buscamos proporcionar una visión global del estado actual de las experiencias clínicas logradas por el PU da Vinci en Urología y discutir las perspectivas futuras.
Se realizó una revisión bibliográfica no sistemática centrada en artículos de cirugía urológica de puerto único utilizando los motores de búsqueda Medline/PubMed y Embase. Los autores analizaron los hallazgos y se describió un breve informe de la experiencia clínica de los procedimientos quirúrgicos llevados a cabo mediante la plataforma PU.
Los datos actuales disponibles de la cirugía robótica de puerto único han establecido la seguridad y la viabilidad de los procedimientos urológicos que utilizan esta novedosa plataforma. Sin embargo, los resultados provienen de series de casos de un solo centro, cohortes pequeñas y estudios retrospectivos que deben ser interpretados con cautela. Se necesitan estudios adicionales para determinar el valor de la plataforma de PU en la comunidad urológica.
El sistema robótico de PU abre nuevas fronteras en el escenario quirúrgico facilitando la realización de cirugías urológicas a través de una única incisión. Se necesitarán más estudios comparativos para evaluar los resultados oncológicos y funcionales perioperatorios y a largo plazo entre los abordajes de PU, robótico multibrazo y abierto.
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